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Being open about mistakes is the first step in learning from them in the NHS

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There are numerous examples in all walks of life that prove being open and honest is the best course of action to take when a mistake is made. The results of mistakes can be disastrous for those involved, and even more so for those who were unaware of the mistakes made. Immediately springing to mind are examples like Nick Leeson’s trading mistakes that bust a bank (Barings) in the mid-1990s, and the mistakes made by BP that contributed to the Deepwater Horizon disaster, with untold environmental issues.

Closer to home, forgetting to buy a ticket in a car park can lead to an unwanted fine, as could inadvertently speeding.

But what about in the NHS? What are the consequences of mistakes made in healthcare, and how can we learn from them?

How disastrous can mistakes be in the NHS?

In the GP practice and across the NHS and healthcare services, mistakes can lead to far worse than financial consequences. Here in the UK, a 2012 study found that 12,000 people die every year because of basic errors by medical staff.

Such deaths observed in the study included:

  • A middle-aged man who was treated for infection after a cyst was removed from his neck. Staff failed to notice that he was not responding to antibiotics until it was too late.
  • A 40-year-old obese woman was in hospital for three weeks while doctors investigated the cause of her vomiting and weight loss. The discovery of ovarian cancer came too late, and she died from blood clots caused by prolonged bed rest.
  • A 22-year-old man died from dehydration caused by neglect in St. George’s Hospital in South London. He had even telephoned police in his quest for a drink of water.

What causes mistakes?

Whatever they are and wherever they occur, mistakes are made because of the same factors. In the last case cited above, the Deputy Coroner, Dr Shirley Radcliffe, said that Kane Gorny’s death had been avoidable. “Kane was undoubtedly let down by incompetence of staff, poor communication [and] lack of leadership, both medical and nursing,” she said.

The solicitor acting for Mr Gorny’s family said they were devastated by the number of missed opportunities to prevent his death.

What can be learned from mistakes?

Where there is a culture of hiding mistakes or refusing to discuss them and learn from them, the outcomes can be disastrous, no more so than in the line of healthcare. It’s important for people to be honest about mistakes made; could Mr Gorny’s death have been prevented if staff had communicated more effectively, or if someone had taken a lead?

Only by admitting and analysing mistakes can we learn from them. In this regard, the GMC has produced guidance to help all healthcare professionals work to a common professional standard when mistakes are made. This guidance reiterates:

  • The importance of being open and honest with everyone concerned – patients and colleagues, for example – when a mistake is made;
  • The importance of an apology, without admitting liability for something that wasn’t your fault;
  • That reporting and learning from mistakes is important to inform future judgement;
  • The need to encourage others to be candid when things go wrong.

Encouraging a culture of candour in the GP practice

There are strategies you can employ to create a culture of openness and honesty within the GP practice. One practice that I visit tells me that they dedicate a part of team meetings to discussing mistakes, with no blame accorded. This open and honest approach has created an environment in which staff immediately learn from their own mistakes and those of others.

More importantly, this approach has led to a more collaborative approach to providing medical care and advice. Staff feel more able to admit a mistake quickly, and that means it can be dealt with when corrective measures are most easily made and most productive: immediately.

Do you have a policy to promote candour and learning from mistakes made? Share your experiences with us so that others can learn best practices from the best practices.

Further reading:

GMC Guidance – Openness and honesty when things go wrong: the professional duty of candour .

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